Practising person-centred care. Selected abstracts from the virtual 26th WONCA Europe conference, 6–10 July 2021

Abstract Background From 6 to 10 July 2021, WONCA Europe and the Dutch College of General Practitioners as host organiser welcomed 1,266 family physicians/general practitioners, teachers, researchers, and students from 66 countries interested in sharing knowledge, experience and innovations in primary healthcare. Methods In cohesive sets of plenary presentations, round table sessions, and research masterclasses, aspects of patient care, research, and education around Practicing Person-Centred Care were presented and discussed. Actual topics in primary care such as covid-19, e-health and professional health, were covered in oral presentation sessions, one slide 5-minutes presentations, case presentations by young doctors and the e-poster gallery. All sessions were recorded and available on-demand for registrants until three months after the conference. All accepted abstracts have been published in the abstract book [https://www.woncaeurope.org/page/past-conference-abstract-books]. For this Journal, we selected the top 20 abstracts based on reviewers scores (mean of 3.5 or higher on a scale of 4) and consensus among members of the Scientific Committee. Results The selected abstracts are divided into the following themes: (1) clinical topics often encountered in primary care, such as acute chest pain, urinary tract infections, dementia, and covid-19 (N = 5); (2) personalised care and related issues such as addressing multimorbidity (N = 2); shared decision making and patient empowerment (N = 4); (3) overdiagnosis and overtreatment, focusing on deprescribing (N = 2); (4) health promotion and prevention, including mental health (N = 2); (5) quality and safety (N = 2); (6) professional development and education (N = 1); (7) research and innovation, including teleconsultation (N = 2).


Introduction
In July 2021, WONCA Europe and the Dutch College of General Practitioners as host organiser welcomed 1,266 family physicians/general practitioners, teachers, researchers, and students from 66 countries interested in sharing knowledge, experience and innovations in primary healthcare. In cohesive sets of plenary presentations, round table sessions, and research master classes, aspects of patient care, research, and education around the theme Practicing Person Centred Care were presented and discussed. Other actual topics in primary care, such as covid-19, e-health, and professional health, were covered in oral presentation sessions, 1 slide 5 minutes presentations, case presentations by young doctors, and in the e-poster gallery. All sessions were recorded and were available on demand for registrants until three months after the conference.
All accepted abstracts are published in the abstract book [https://www.woncaeurope.org/page/past-conferenceabstract-books]. For this Journal, we selected the top 20 abstracts based on the reviewers score (mean of 3.5 or higher on a scale of 4) and consensus among members of the Scientific Committee.
Background: Telephone triage is fully integrated into urgent primary care in the Netherlands. The underlying triage protocols do not consider possible differences between men and women. Objectives: We aim to evaluate sex-specific differences for acute-onset chest pain, a key symptom in which adequate triage is pivotal. Methods: A retrospective cohort study of consecutive patients who contacted a regional, urgent primary care facility in Alkmaar, the Netherlands in 2017. We performed descriptive analyses on sex differences in patient and symptom characteristics, triage assessment and subsequent outcomes. Results: A total of 1,804 patients were included, the median age was 54 years and 57.5% were female. Women more frequently reported centrally located chest pain (32.2 vs. 27.7%), nausea (23.4 vs. 15.7%) and radiating pain to the back or jaw(s) (9.5 vs. 5.9% and 5.8 vs. 2.5%, respectively). Cardiovascular comorbidities were less common among women (47.5 vs. 54.3%). Triage urgencies were comparable between men and women, with comparable ambulance activation rates. However, women were more often visited at home (10.9 vs. 7.4%). At follow-up, women less often had an underlying cardiovascular condition (21.1 vs. 29.7%), including acute coronary syndrome (5.3 vs. 8.5%) compared to men. Conclusion: There are considerable differences between women and men who contact urgent primary care with chest pain. Notably, women have different symptom presentations, fewer cardiovascular risk factors, and lower risk of an underlying cardiovascular condition compared to men. Despite being at lower risk, ambulance activation is comparable between women and men.

Consultations and antibiotic treatment for urinary tract infections in Norwegian primary care 2006-2015, a registrybased study
Background: Extensive use of antibiotics and antimicrobial resistance is a major concern globally. In Norway, 82% of antibiotics are prescribed in primary care and one in four prescriptions are issued to treat urinary tract infections (UTI). Objectives: This study investigated time trends in antibiotic treatment following consultations for UTI in primary care. Methods: Registry-based study using linked data on all patient consultations for cystitis and pyelonephritis in general practice and out-of-hours (OOH) services and all dispensed prescriptions of antibiotics in Norway, 2006Norway, -2015 Results: Of the 2,426,643 UTI consultations, 94.5% were for cystitis and 5.5% for pyelonephritis; 79.4% were conducted in general practice and 20.6% in OOH services. From 2006 to 2015, annual numbers of cystitis and pyelonephritis consultations increased by 33.9 and 14.0%. Proportion of UTI consultations resulting in antibiotic prescription increased gradually for cystitis (36.6-65.7%) and pyelonephritis (35.3-50.7%). Cystitis was mainly treated with pivmecillinam (53.9%), and trimethoprim (20.8%) and pyelonephritis with pivmecillinam (43.0%), ciprofloxacin (20.5%) and sulfamethoxazole-trimethoprim (16.3%). For cystitis, the use of pivmecillinam increased the most (46.1-56.6%), and for pyelonephritis, the use of sulfamethoxazole-trimethoprim (11.4-25.5%) and ciprofloxacin (from 18.2-23.1%). Conclusion: During the 10-year study period, there was a considerable increase in UTI consultations resulting in antibiotic treatment. Treatment trend for pyelonephritis was characterised by more use of broader-spectrum antibiotics. These trends, indicative of enduring changes in consultation and treatment patterns for UTIs, will have implications for future antibiotic stewardship measures and policy. Telephone registration and nurse-triage, from offices located above the clinic In clinic assessment and testing, via drive-through or in-room consultation, determined clinically Post-consultation notification of results to the patient and their regular GP, and data reporting.
Health assistants book appointments, guide patients, assist with infection control, remotely transcribe consultations (using video consultation from the clinic) and complete post-visit notifications. New staff are trained using a buddy system. Results: The adaptive model entails appointments for sessional vaccination clinics only when a nurse is satisfied that patients have enough information to provide informed consent. Patients attend nurse-led vaccinations in cohorts, guided and supported by health assistants. Vaccination details and notifications are gathered and transcribed remotely by video. Background and purpose: Dementia is a progressive condition having major consequences for affected individuals, their families and carers. However, evidence on how hormone replacement therapy (HRT)increasingly used by women affected by menopauseaffects their risk of developing dementia is unclear. All previous studies have been relatively small short-term or have not accounted for some confounding variables.
Methods: Two nested case-control studies used the UK primary care databases, QResearch and CPRD. Overall between 1998 and 2020, 118,501 women aged 55 and older were diagnosed with dementia and were matched by birth year and practice to up to five controls, alive and registered at the time of case diagnosis (index date). Exposure to HRT was based on prescriptions excluding those within three years prior to the index date. Risks for different types of HRT and duration of use were analysed using conditional logistic regression, adjusted for life-style factors, comorbidities and other drugs. Analyses were run for each database and results combined using meta-analysis techniques.
Conclusion: This is the largest consistent study providing population-based risk estimates. The findings should assist doctors and patients considering HRT treatments.

PERSONALISED CARE
Optima Formatowards a patientcentred multimorbidity approach for chronic disease management in primary care Lena Raaijmakers a , Erik W. M. A. Bischoff a , Jan Vercoulen b and Tjard Schermer a a Primary and Community Care, Radboudumc, Nijmegen, Netherlands; b Medical Psychology, Radboudumc, Nijmegen, Netherlands Background: To reduce the burden of chronic diseases on society and individuals, European countries implemented disease management programmes (DMPs) that focus on a single chronic disease. However, (i) the scientific evidence that these DMPs reduce the burden of chronic disease in terms of health-related quality of life is not convincing, (ii) patients with multimorbidity may receive overlapping or conflicting treatment advice, and (iii) the single disease approach conflicts with the core competencies of primary care, i.e. medical generalistic, person-centred, and continuous care.
Objectives: This study aimed to develop a holistic, personcentred and integrated approach for the management of patients with chronic diseases and multimorbidity in primary care.
Methods: A mixed-methods study was conducted in the Netherlands from January 2019 to December 2020. First, we performed a scoping review to construct a theoretical model. Second, 57 healthcare professionals commented on the model in online qualitative questionnaires. Third, 9 patients with chronic conditions were interviewed on the model by phone. Finally, the model was presented to 3 local primary care cooperatives and finalised after their comments.
Results: A stepwise software-supported approach was developed, including (i) assessing patient's integral health status using (web-based) questionnaires and physical measurements; (ii) discussing the results with a case manager, after which (iii) treatment goals are formulated, suitable interventions in the primary care network are selected and an evaluation is planned. Conclusion: We developed a holistic, person-centred, integrated approach for managing patients with chronic diseases and multimorbidity in primary care. This approach will be tested in a pilot study in 2021 to establish its feasibility and potential effects. (1) satisfaction with current medications, (2) experience of taking too much medication, (3) major side effects, (4) experience of taking unnecessary medication, and (5) medication-related topics to discuss with the GP (open-ended question). The PREPAIR tool was completed by the patient before the GP consultation to encourage patient reflections on own medications. During the consultation, the GP's focus changed from the computer towards the patient, questionnaire responses were reviewed, and potential medication-related problems were discussed. The patients were empowered to speak, and the GPs improved their understanding of patient perspectives on medications. Although some GPs suggested a broader scope on health perspectives, the PREPAIR tool was received positively by both patients and GPs. Conclusion: We developed a brief and valuable tool to support systematic patient involvement in general practice. Future research should address whether the PREPAIR tool can contribute to improved patient outcomes and quality of care.
A systematic approach to identify and prioritise option tables for recommendations in NHG-guidelines Background: Clinicians, researchers, and Alzheimer Societies stress the importance of an early dementia diagnosis in a mild stage. However, whether this is an improvement in patients' health and well-being is still debated. Ideally, shared-decision making (SDM) is implemented to discuss the potential benefits and harms of an early diagnosis and disclosure with patients.
Objectives: This study explores experiences and considerations of GPs regarding an (early) diagnostic trajectory for dementia and implementation of SDM therein.
Methods: In this qualitative study, GPs and practice-based nurses were interviewed. Topics included views concerning early dementia diagnosis, the decision-making process for starting a diagnostic trajectory, and views on the implementation of SDM in this regard. Results: Sixteen GPs and practice-based nurses in the Netherlands were interviewed. Several considerations concerning the timing of a dementia diagnosis were identified, including; (1) decrease in patients' quality of life (QoL) due to an (early) diagnosis, (2) potential advantages of an early diagnosis for patients and their significant others (3) the possibility of a misdiagnosis (4) experiences related to a dementia diagnosis in a late disease stage. Results: Several patient and dyad related factors were identified that could hinder or facilitate the implementation of SDM in general practice. Conclusion: Most GPs favoured a timely (instead of an early) diagnostic trajectory (i.e. initiated at the right time for patients and significant others to meet their needs and expectations) and emphasised the importance of their patients' QoL. GPs favoured patient involvement in deciding on an (early) diagnostic trajectory, but several barriers and facilitators (e.g. patients' expectations regarding treatment) affect SDM. Background: Long-term antidepressant use, much longer than recommended by guidelines, can harm patients and generate unnecessary costs. Most antidepressants are prescribed by general practitioners (GPs) but it remains unclear why they do not discontinue long-term use.
Objectives: This study aims to explore GPs' views and experiences of discontinuing long-term antidepressants, barriers and facilitators of discontinuation and required support.
Methods: This is a qualitative study including 20 semi-structured face to face interviews with Belgian GPs. Interviews were analysed thematically.
Results: The first theme, 'Success stories' describes three strong motivators to discontinue antidepressants: patient health issues, patient requests and a new positive life event.
Second, not all GPs consider long-term antidepressant use a 'problem' as they perceive antidepressants as effective and safe. GPs' main concern is risk of relapse. Third, GPs foresee that discontinuation of antidepressants is not an easy and straightforward process. GPs weigh up whether they have the necessary skills and whether it is worth the effort to start this process. Conclusion: Discontinuation of long-term antidepressants is a complex and uncertain process for GPs, especially in the absence a facilitating life-event or patient demand. Absence of a compelling need for discontinuation and fear of relapse of symptoms in a stable patient are important barriers for GPs when considering discontinuation. To increase GPs' motivation to discontinue long-term antidepressants, more emphasis on the futility of the actual effect and potential harms related to long-term use is needed. Background: Couple relationship satisfaction is related to physical and mental health and longevity. In a Norwegian study from 2020, one in four patients reported talking about their couple relationship with their general practitioner (GP).

HEALTH PROMOTION AND PREVENTION
Objectives: This study explores how GPs' experience couple relationship problems and how they identify patients with couple relationship problems.
Methods: This is an exploratory qualitative study. In 2020, we conducted three semi-structured focus group interviews with 18 GPs. We developed a semi-structured interview guide and used systematic text condensation for the inductive analyses.
Results: All participating GPs reported an abundance of experiences handling couple relationship problems in their practice. These issues both served as explanation for relevant clinical problems and were important in a holistic approach to the patients and their families. The GPs had different amounts of training in psychotherapy. Some emphasised that doctors learn communication skills useful for individual consultations in medical education but do not develop skills for dyadic counselling. The most experienced GPs felt qualified to support patients with couple relationship problems, though none of the participants could see themselves as couples therapists. Some wanted specific tools for the GP to use when this issue is brought up. Conclusion: Experienced GPs are comfortable having supportive conversations with individual patients regarding couple relationship problems. GPs could need more skills in coping with patients' relational problems and dyadic counselling. A first-aid-kit for GPs facing patients with couple relationship problems might be useful. . Linear mixed models were used to determine the association between continuity level and practice characteristics, adjusted for patient characteristics. To identify additional factors associated with personal continuity, we conducted interviews with general practitioners working in practices with the largest difference between observed and predicted continuity. Results: We identified nine practice characteristics significantly associated with continuity of care (p < 0.05). Of these characteristics, six were significant in all models: number of registered patients; number of doctors and their working days; number of locums and their percentage of contacts; number of other employees. These effects were adjusted for patient characteristics, including type of contacts, age, sex, medical history, time of registration, and ancestry (p < 0.05). Interviews may provide insights in additional factors (analyses will be completed). Conclusion: Six characteristics were associated with higher continuity of care, which can be calculated using general practice data. Optimisation of these characteristics may contribute to improving personal continuity. Objectives: This study aims to analyse patient complaints (PC) in 4 health areas of Aragon Health Care Service (Spain)covering 958,000 inhabitants-and identify those related to patient safety issues. Methods: A simple random sampling was performed regarding all the claims issued in 2017 for primary care facilities. The total sample was 324 claims. Peer review was made with a checklist to identify PSI considering: sex and age of the patient, nature of PSI, professional involved, place of healthcare, severity, and avoidability of harm. Claims were reviewed by two researchers (kappa concordance test 0.94) and a third independent reviewer for disagreements. The three were family doctors. Results: 24.3% (84/324) of claims are due to PSI. Family Doctors received 44.9% of claims. Among the PSI detected (84), 52.3% were due to problems in the healthcare process and 23.5% to coordination between care levels and waiting times. Regarding causal factors, 51% involved diagnosis and 24.9% management and communication issues. A total of 39/ 84 were PSI with harm, of whom 4/84 (6%) were moderate and 2/84 serious harm. A total of 2.6% (1/39 PSI) were unavoidable while 97.4% (38/39 complaints with PSI) could have been avoided. Conclusion: Patients' claims content PSI. The analysis and follow-up of PSI claims can be considered as a source of information to improve PS in primary care.

PROFESSIONAL EDUCATION AND DEVELOPMENT
Developing educational resources to improve primary healthcare services for people with deafness and hearing loss

Devina Maru Royal
College of General Practitioners, National Clinical Champion For Deafness and Hearing Loss, London, United Kingdom Background: Twelve million people have hearing loss in the UK. GPs have identified a lack of training in the necessary skills to communicate effectively with people who have hearing loss, and this has presented a clear learning gap. Evidence suggests that people wait on average 10 years before seeking help for hearing loss and 30-45% presenting to their GP are not referred to NHS audiology services. Methods: To address this knowledge gap, a diverse stakeholder group was formed with The Royal National Institute for Deaf People, NHS England/Improvement, RCGP and the patient public voice community to tackle the barriers impacting hearing health and to raise awareness. A toolkit of educational resources was developed, including podcasts, videos, screencasts, online courses, which GPs, trainees and members of the wider primary care team could access, engage and receive appropriate training and support. Results: 19,850 CPD tinnitus module users; 3,659 podcast listens; 2,576 number of toolkit views. RCGP core curriculum updated with references to hearing loss. RCGP accredited its first Deaf awareness online course for doctors. NHS England bulletin and BJGP article published a piece highlighting the educational resources for use in primary care. Conclusion: Resources developed give GPs and trainees the confidence to recognise the symptoms of hearing loss and appropriately refer for a hearing assessment promptly. It signposts resources to help with remote consulting and covers new additions of the core curriculum to hearing loss. The toolkit provides QI initiatives and helps GP surgeries comply with legislation (Accessible Information Standard and Equality Act), which CQC inspects. Background: In the context of the 2020 SARS-CoV-2 pandemic, healthcare services had to get reorganised and resorted to teleconsultation in their clinical practice.

RESEARCH AND INNOVATION
Objectives: This study's primary goal is to know the Portuguese Family Doctors' perspective on the utility of teleconsultation in their future clinical practice. Second, to recognize advantages and disadvantages of teleconsultation, identify possible difficulties and under what circumstances it may represent added value. Methods: A cross-sectional study was realised between September 2020 and January 2021 through the application of an online questionnaire. The target population was family